Kudos to the American College of Physicians (ACP), the medical society that represents Internists, for taking a leadership role in the battle against waste in healthcare. The College’s recently published Ethics Manual (Sixth Edition) clearly points out that physicians not only have an obligation to individual patients, but also to society. In particular, the College takes on the issue cost-effectiveness of care pointing out that:
”Physicians have a responsibility to practice effective and efﬁcient health care and to use health care resources responsibly. Parsimonious care that utilizes the most efﬁcient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available.”
As health care costs continue to gobble up more and more of America’s money, leaving less and less for other items of importance, such as food, housing, education, and infrastructure, it is critical that physicians are as thoughtful about evaluating the value of their decisions as they are about all other aspects of care they provide to their patients. This includes decisions about which diagnostic and screening tests they order. We can no longer afford a “check all the boxes” approach to test ordering.
An editorial in the January 17, 2012 issue of the Annals of Internal Medicine suggests that “High-Value Testing Begins with a Few Simple Questions.” They propose a short list of questions physicians should ask themselves before ordering tests. I think these questions should be asked and answered not only by physicians but also by their patients. Reigning in the healthcare cost demon requires participation by the entire team.
Questions to ask before ordering or accepting a medical test
Before a test is ordered (or agreed to), these questions (modified from the ACP list) should be asked and answered by both the physician and the patient:
- Has this test been done before? If yes, when was it done and what was the result? If you don’t have the results right now, can you get them so that you don’t have to repeat the test? Do you really have to repeat the test just because “it wasn’t done here?” The ACP editorial suggests repeat testing because of distrust of another institution’s results is usually not justified. And, now the big question: If the test is repeated, is it likely to be significantly different from the last result? For example, if the LDL was high 6 months ago and nothing has changed with regard to diet, weight, or medications, how likely is it that the LDL level will meaningfully different now?
- Will the test result change anything? Will it lead to a new treatment or recommendation for behavior change? Will it motivate the patient to eat better, exercise more or drink less? Or is it just “nice to know?” A friend recently told me he really wanted to get an MRI of his knees. I asked him if he had problems with his knees, he said no, he just want to know they were ok. Patients and their family members should be asked why they want the test…what is it they hope the test will do for them? Can the “itch” be scratched in a different way – with a physical exam where the key findings are pointed out and explained?
- What are the probability and potential adverse consequences of a false-positive result? Too often both docs and patients think there are no downsides to getting a test…more is better, right? But tests do have consequences ranging from radiation in the case of imaging to bruising and tenderness after a blood draw. False positives can make patients anxious until they are proven to truly be a false positive. They can also lead to further, sometimes more invasive, testing with related expenses and related risks. Remember when consumers were flocking to the total body imaging centers about a decade ago? My sister-in-law was gifted such an image only to learn that she had a potentially abnormal finding – something clinicians call a Ditzel or incidentaloma. As is often the case, this finding was evaluated further (“worked-up” in the language of medicine) and turned out to be nothing of importance. But doing the work-up required more testing, more time, more money, and more anxiety. By understanding and discussing the probability that a test will yield an actionable result and the consequences of a false-positive, the doctor and patient can decide whether the test should be done.
- Is there a potential danger in the short term if this test is not obtained? How often have you ordered a test “just to be safe?” Or had a patient (or family member) badger you into ordering an x-ray or CT to be sure that a highly unlikely condition was not present. Ok, I know some of you are thinking, well sure I did, because if I didn’t I would get sued or the patient would be unhappy with me and go elsewhere or give me a bad review on DoctorBase or Zocdoc. This certainly needs to be taken into account, but it should not be the sole or even major driver of test ordering behavior.
- Both physicians and patients should ask the “why” questions:
- Why am I ordering the test? Hopefully, the answer will be something like this: Mrs. B started on a diuretic a month ago, I need to make sure her potassium is in the normal range. Not like this: I check potassium on all my patients because you never know what you will find.
- Patients need to ask (or be asked) why do you want that test? What are your worried about? What do you hope to learn from it? Is there another way I can get the answer I need?
Now, I know that it is easier to write about stuff like this than to actually do it. But I think the ACP is onto something here. Controlling the ever-increasing costs of healthcare is going to require that we are vigilant about everything we do (or in the case of patients, ask for). Some might argue that CBCs or Chest X-rays or even CTs and Echocardiograms are cheap compared to other big ticket items in health care like hospital stays or cancer drugs. So why focus testing as a cost containment mechanism? But if we have learned anything over the last several decades of trying to address the cost problem, there are no silver bullets. If there were, they would have been found and used a long time ago. Rather, there are thousands of golden BBs-each one of which needs to be aimed at a different part of the cost problem, large and small, so that the result, at the end of the day, is high-value health care. Easier said than done? Yes, but contributions, such as the one that the ACP has made with respect to high-value testing are a good addition to the cost control armamentarium